not taking notice of those around me, not connecting, and not taking in all that is available in the moments.

This video reminds me to slow down and be mindful of those around me and to stop and take in each and every moment as if it were our last.

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My friend and partner spoke at the grave site and said that he has been angry and questioning God only 2 times in his life: The first when Robbie was born, and the now the second when God took Robbie from him.  WOW! The powerful truth that so often the only way to the mountain tops is through the valleys of life.

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The typical Inquiry remains the dreaded yearly or quarterly employee evaluation.  This is the place where the boss critiques the employee.  We have all been ‘evaluated’, and we have all been found wanting.  Even if you receive a glowing evaluation, it takes only one ‘but’ to ruin it.  “You continue to do an amazing job, BUT you could improve in this or that…”  We are convinced that this negative feedback is essential and productive.  BUT if you are at all like me, I only hear the negative, and it burns into my heart.  I go sleepless for days stewing over my critique.  In fact, the negative causes me often to be counterproductive, frustrated, sad, depressed, discouraged, etc.
 
now in a parallel universe:
 
Your boss calls you into a room and gives you a list of sincere appreciation.  A list of blessings. A list of all the great things that you do.    Would your productivity go up? Would you work harder? Would you sleep well that night? Would you wake up excited to go to work the following day? Would you appreciate and encourage my co-workers and boss more? Would we all be more likely to smile, laugh, encourage, and bless those around us???

Now What?

What if we started to sincerely appreciate those around us? What if we took the time each day to choose someone to bless with words of affirmation? Can we all try this? I did.  WOW!  It almost brought the person to tears…it is THAT powerful.  If we all got into a rhythm of daily blessing those around us with words of encouragement, what might happen?? Please share with us your experience in trying this…

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I also just finished Blue Like Jazz by Donald Miller. He points out that it is not our responsibility to change anybody (and as Carnegie has pointed out, you can’t so stop trying!).  We can, however, try and see them as God does (as a beloved son or daughter) and love them as God does (unconditionally).  By putting away our ‘judgmentalism and pride and loathing of other people’ and instead treat everybody ‘as though they were [your] best friend’, they will change for the better.

When organizations discover that they are having a problem, they get a team together to look at the problems and try to find a solution better known as problem solving.  About 10 years ago, a team of expert problem solvers were hired by a large corporation to come in to ‘fix’ their problems in hopes of increasing their production rates.  They found that after their problem solving their production rates actually went down instead of up.  Puzzled, they tried a different method.  Instead of looking at the problem and filling everyone with negative thoughts about each other and the organization, they looked at the positive.  They looked at all the things that worked well, and they focused on making them work even better.  The production rate soared.  This method is known as Appreciative Inquiry.

It has been thought that allowing and encouraging people to air their grievances about other people in the organization and list their complaints about others and the organization is the path to improvement.  This has been shown time and time again to have the opposite effects. It produces negativity, discourages others from working harder to make things better (why bother if you are only going to hear the negative from a select few?!), and it creates a work environment that is defeatist, negative, counter productive, and filled with cattiness and  pettiness.  So next time your organization decides to send out questionnaires to critique, or wants to create a work group to problem solve, I would hope we all can consider Appreciative Inquiry and the wisdom of Carnegie, Miller, and Christ.

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Chess With God

Boris D. Veysman, MD

[Ann Emerg Med. 2010;55:123-124.]

Give me a bad position, I will defend it. Openings, endgames, complicated positions, dull draws, I love them and I will do my very best.—Hein Donner, Chess player, 1950

Not only does God play dice, but… he sometimes throws them where they cannot be seen.—Stephen Hawking

Amidst a busy shift when patients pile in, seasoned nurses start to grumble, and my blood sugar and bladder volume are most discordant, I overhear a fourth-year medical student share wisdom with a third-year newbie. “ER’s got a good schedule if you like doing overpaid triage.” I smile, enjoying the involuntary adrenaline boost from sublimated anger, before refocusing on the labs of the 80-year-old woman with digoxin toxicity and acute renal failure, presenting with runs of unstable tachycardia, prolonged QT interval, hyperkalemia, hypocalcemia, and a filthy cough suggesting preseptic pneumonia.

The next 20 seconds is a synaptic typhoon. Could elevated lactate mean not sepsis but mesenteric ischemia? A benign exam would not rule it out, and she is too sick to complain of abdominal pain. Tachycardia and hypoxia suggest pulmonary embolism (PE), given her edematous legs and recently stopped Coumadin when she had a GI bleed. This also increases the risk of mesenteric clot. Yet the contrast timing is different for CT angiograms of chest and abdomen, and I will have to choose which to optimize. Both studies are perilous because of the dye load, given acute renal failure, but failure to make either diagnosis would be fatal in a patient this sick. Meanwhile, empiric anticoagulation risks another massive GI bleed. Dialysis and transfusion may be necessary damage control to be considered concurrently with the diagnostic studies. Furthermore, calcium gluconate is contraindicated in digoxin toxicity because of mostly hypothetic cardiac tetany but would probably help with the blood pressure. Calcium would also treat hyperkalemia and hypocalcemia (strangely equal at 6.5), which both contribute to cardiac toxicity. If the heart gives out, it’s my fault either way, and I find that liberating. Digibind for the hyperkalemic digoxin toxicity, but that will worsen the heart failure. Definitely fluids for hypotension and sepsis but absolutely no fluids because of pulmonary edema and renal failure.

“Dr. V, she’s 80/50,” the nurse reports. Time’s up. Make a move….

We may choose emergency medicine for different reasons, but we fall in love all over again when after a few years of practice we begin to understand its magic. For me, it’s the intensity of thought when time is short and stakes are high in a battle against the worthiest of opponents. There are many hard cases that challenge the depth of our ability and ingenuity. We believe that God plays fair and you often get a shot at winning, regardless of how dismal the malady. A broad differential and rapid and often imperfect diagnostics are often the only way to find in time what’s lethal and irreversible. And before the diagnostics are back, preemptive strikes of empiric therapy based on calculated risks and hunches may earn you a guerrilla victory.

There are no simple cases. Not at this level. There are simple doctors unwilling to try harder to optimize efficiency, cost, and outcomes, to do it with less radiation exposure, fewer side effects, and higher real and perceived quality. Every ankle and ear doesn’t need radiographs and antibiotics, but some do, and most need thoughtful pain management and anticipatory guidance, with the entire encounter limited to only a few seconds by more pressing cases. Every patient, sick or well, is a chance to be our best, to recognize when our best is not enough, and to get help before it’s too late. If it were easy, I wouldn’t want to do it.

When consultants who see the patient the next day whine about “shotgun workups,” “excessively broad antibiotics,” and “inconsistent management,” emergency physicians laugh nostalgically and think, “that was a good save.” However lacking in elegance the evaluation may appear to the hammer who sees the world as a nail, he should have spoken when he was somehow unavailable at 2 am on a Saturday. We are emergency specialists and we step up to the board, for anyone, at any time, and with a unique skill set.

We know that you don’t always get second chances playing against God. Specialists wishing to “see the patient in the morning,” surgeons who interrupt with “what did the CT scan show?” and primaries requesting to “wait for the blood cultures before treating” are occasionally right, but more often they fail to feel our sense of urgency and appear not invested in the battle. Seasoned ER docs are not desperate for approval, camaraderie, or admiration; often we can even write a rain check on respect. When squaring off against our adversary 30 times a shift, self-respect is earned and goes a long way toward self-esteem. But we deserve alliance, for others to be on our side in caring for the patient. This means trusting our instincts. This means respect for our expertise in ambiguity and patients who don’t read the textbook.

The metal doors burst open and the paramedics roll in a man who looks grayer than the sheet. “All we know is he’s got a kidney pancreas transplant with a pacemaker and he’s been depressed lately. We found him unresponsive next to some pills. Good vital signs in the truck but now I can’t feel the pulse.” The third-year med student stares blankly at the paramedic, while the fourth-year looks close to passing out. The nurses run to the gurney to transfer the lifeless body onto the stretcher, begin working on access, connecting leads. I stand up slowly and take a deep breath. The board is set; the next move is mine.

Welcome back, old friend. You open well. Let’s play….

Chess With God

Boris D. Veysman, MD

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“I heard a guttural scream,” Rich says, “and a man was handing me his lifeless son.”

“How old?” I ask.

“Nine months. We worked on him for over an hour.”

Rich moves his chair, coughs. It’s freezing in the conference room. [Note: For privacy, nurses are mentioned only by first name.] The muffled din of the emergency room is audible through closed metal doors. It’s 7 a.m., and Rich’s 12-hour shift has just ended. “I flashed to something I heard once about how a casket doesn’t weigh very much—just enough to break a father’s heart,” he says, “and I lost it. I’m standing there, between beds one and two holding that dead baby, and I’m sobbing. I am in charge, and I’m crying.”

As an 11-year volunteer in Cedars-Sinai Medical Center’s emergency room, I’ve seen close up what ER nurses deal with. It takes rare emotional courage not to burn out when you know that every time those doors open—whether you are working triage in front, where a guy may stumble in with a heart attack, or in back, where paramedics may race in with a girl who has been knifed or shot—it’s bad news. Then there’s the physical strength required to survive 12-hour shifts with two half-hour breaks and 45 minutes for lunch. ER nurses never sit. But it’s the children—every ER nurse will tell you—who take the biggest toll.

“For a very long time,” Rich says, “I viewed it as a badge of honor—How much crap can I take? How much horror can I see and not show emotion?” He clears his throat. “But you can’t keep stuffing it down; you have to deal with the emotion.”

Rich has been a nurse for 22 years. He has a 12-year-old son. There are 98 nurses in Cedars’ ER. Their ages range from 24 to 67, and they are as different as heavy metal is to polka. What they share are guts and a desire to give. “I was an operating-room tech in the army. My CO said, ‘Nursing?’ And I thought, Maybe,” Rich says.

He is big and bulky, with soulful eyes and a wild sense of humor. When I ask why he really became a nurse, he jokes, “I liked the cute little hats, the white nylons and the sensible shoes.”

Rich was diagnosed with leukemia last year in his very own ER, when he showed a doctor some large bruises on his body. The doc ran tests while Rich was on shift and returned with the diagnosis. The story goes that he asked the doc if he could finish his shift so he wouldn’t get docked pay. After eight months off, five rounds of intravenous and oral chemo and too many bone-marrow biopsies, Rich is back working nights. I don’t know how he does it. I don’t know how any of them do it.

“It affects your soul,” Melissa says. She could be called the queen of trauma, having done 20 years in what she terms “the knife and gun club” at St. Luke’s Roosevelt Hospital in Harlem and five years in Newark, New Jersey, before coming to L.A. “Newark made New York look like kindergarten,” she says.

Hearing Melissa’s accent is like flying to N.Y. and walking into Original Ray’s. She recalls a guy “who was having a big heart attack in room nine…In the middle of his pain, he heard me, looked up and said, ‘What part of the Island are you from?’ ”

“Why nursing?” I ask.

“I had a scholarship to the American Ballet Theatre, and I was good, but I wasn’t brilliant…and my dad said, ‘You need an education—go be a nurse.’ ”

I can’t imagine Melissa in ballet shoes, but 29 years ago, she traded them for a stethoscope. We’re at Orso, across the street from Cedars, having dinner after Melissa’s 7 a.m.–to–7 p.m. shift. She’s wearing a chic black jacket over blue scrubs, but there are smudges under her eyes. “Where do you find joy in the job?” I ask.

Without blinking, she says, “Using my knowledge to participate in stopping bad things that happen to people.”

Of course, they can’t always be stopped. You can’t stop a mother’s pain when her 18-month-old drowns. “The mom was still wet,” she says, “making a puddle by room three. When she knew her baby was gone, she wailed…just melted to the floor.” She pauses. “I swaddled her in warm blankets. It was all I could do for her.”

“What do you do for you?”

“I compartmentalize,” she says, finally smiling. “And I buy very expensive shoes.” She must have a closet full of Manolos.

Shari runs to cope with the stress. She did the 2007 Boston Marathon. “I’ve also run after psych patients who escaped the ER and took off down Gracie Allen toward 3rd Street.” She works mostly as a charge nurse, overseeing patient flow. If paramedics bring you in on a gurney, you’ll see the charge nurse first. That’s who decides whether the man in room four gets kicked into the hall because the room is needed for the woman the LAFD just scooped up off the pavement.

Some ER nurses charge, but all work triage and patient care. There are approximately 15 nurses on each shift, and shifts change all day. There are 41 beds in the ER—58 if they fill the halls. Cedars is a number one trauma center—the wait can be 10 minutes or four hours. Think of all the L.A. hospitals that have closed.

Shari, who was raised on a farm in Racine, Wisconsin, has been a nurse for 21 years. The only other job she considered was a baker…and that was when she was five. “How come you didn’t do that?”

“They have to get up really early,” she says, taking a bite from her perfectly wrapped homemade sandwich. She expertly cuts her peach with a paring knife.

Shari came on at 11 a.m. and will work until 11 p.m. We’re in the cafeteria on her dinner break, but she looks like she has just showered—blond curls escaping a perfect ponytail—a Goldilocks nurse who behaves like a general. I have seen her hustle a parade of bloody, broken patients through the door with the cool calm of an air-traffic controller moving jets through a bank of thunderstorms.

Abby and Sylvia carpool from Santa Clarita. They call the drive back and forth to Cedars their “psychotherapy hour.” Abby, fast and funny, was born in the Philippines. She has been a nurse 27 years—Hoboken and then L.A. “Why nursing?” I ask.

“I got into the short line,” Abby says, and she and Sylvia fall into a fit of laughter. “I’m Chinese, and when you’re Chinese, you’re supposed to study math—go into accounting, banking. So I went with my girlfriends to apply to school. All of the lines were really long, but there was this one short line, so I got into that one.”

“It was the premed, premed tech and nursing line,” Sylvia adds, smiling widely.

“I passed the test,” Abby says, “and I said to my friends, ‘Nursing?! My mom is going to kill me.’ ”

The ER can bring out the worst in people—not just the patients but the people bringing in the patients. Week after week, I see fear breed anger and despicable manners. I ask Abby how she deals with that. “You can’t take it personally,” she says. “You have to get over it and move on.”

“What’s the joy in this job?” I ask Sylvia, who has three children and has been a Cedars nurse for 19 years—not long enough to dim her radiant smile.

“You get to help people,” she says. “You make a difference.”

The nurses remind me about the funny stuff: the toddler whose potty got stuck on her head when she tried to put it on like a hat; the four-year-old who shoved an aspirin up his nose. “Did you have a headache?” Rich asked the kid.

Some of the nurses are on their second careers. Paul, one of the calmest in the ER, was a Navy SEAL. Jerry, who could find a vein in a stone, was a fashion designer. Joe was in marketing at Anheuser Busch. “And then came 9-11,” he recalls, “and I was watching those firefighters on TV, and I just knew I had to change my life. I had to do something honorable.”

Clean-cut, in pressed scrubs and Clark Kent glasses, Joe is the one you’d want to marry your daughter. “Can you have the same compassion for a drug addict as you do for a cardiac arrest or the patient back for the third time with terminal cancer?” I ask.

“You have to. What about the guy booked on a double vehicular manslaughter, still drunk, spewing ef-yous and showing no remorse? He’d kept driving after he hit them,” Joe says, eyes narrowing. “You have to give him the same care.”

Lots of people are brought into the ER in cuffs—think of gang shootings, car wrecks, domestic violence. Bad guys get hurt just like good guys, and they’re all brought to the same ER.

Kelly wanted to be a cop. “First an actress, second a cop,” she says. Raised in Tennessee and Arkansas, she calls herself a hillbilly but looks like a movie star. She hunts, motorcycles, parachutes and has an 11-year-old son. A nurse for 10 years, she once did CPR on a woman in the ER driveway.

“I was triaging, the doors opened, and someone was yelling for help. It was the sound of the help; the hairs on the back of my neck stood up,” Kelly recalls. “Female, mid seventies, cold as a cucumber, not breathing, in the passenger seat. I pulled her down onto the cement. There wasn’t any time; her feet were still in the car.”

Flor nods. She, Kelly and I are at Du-par’s on their day off. “I did CPR on a doctor once,” she says. “We were moving him to the OR, and he went into cardiac arrest. I jumped up on the gurney, straddled him and did CPR—in the elevator. It probably didn’t look good,” she says, brown eyes wide.

Flor is a “good Catholic girl” from Manila—nuns and rosary beads to Kelly’s bikes and rifles. “My aunt was a nurse in the U.S., and when she’d come home, it was like she was a celebrity. People gathered around—they made a fiesta: We have to kill a pig,” she says, grinning. “They respected her, and I thought, I want to be like that.” She has been a nurse for 31 years. She has three kids in college and looks like she’s their age. “I’m a caregiver,” she says. “That’s what I took the oath for.”

Triage is the hardest, most ER nurses agree. It’s not just the patients’ vitals. What are the skin signs, the alertness, the level of consciousness? Sweaty, pale, faint, red? It’s not just their pain.

“Triage is the most dangerous,” Nili says.

“You use your clinical judgment to assess the patient. You can’t let anyone slip past you, and you can’t make a mistake.” Tall and impressive, if Nili walked into your room with a needle, you’d extend your arm. “Why did you go into nursing?” I ask.

“Oh,” she says shyly, “I was out of control at Cal State Northridge, and my parents said, ‘It’s either nursing school or leave home.’ ” She has been on the job for 16 years. “Not everyone can do it.”

Well, that’s for damn sure. I’ve seen Nili on the trauma team, suited up in blue plastic, waiting for the paramedics to arrive, like a solider about to take a hill. I’ve sat next to her at the radio when the LAFD calls. The silent blue lights in the corners of the ER flash and spin, and a nurse on the blue team hotfoots it to the radio room. “Cedars base, copy,” and the line crackles: “This is Rescue 41. I have a 57-year-old male, altered LOC, in moderate distress; this is Rescue 27, I have a 16-year-old female…” And on it goes.

“Every day is a crisis,” Nili says.

ER nurses don’t give long-term care. They don’t get to know you, and they don’t even know what happens to you after you leave the ER. They are a platoon of adrenaline junkies with invisible capes and angel wings, there to take care of you at your worst moments. And it never ends. “Patients are like waves of ocean hitting the beach,” Shari says. “New ones just replace the old ones.”

“If I have to cry, I cry,” Mark says. “You can’t carry it to the next shift.” Blond and lanky, he has the mischievous air of a reformed bad boy. He did 10 years as a paramedic before his 10 as a nurse, so he has seen his share. “I wanted to be that person who knew what to do, how to run a code—perfectly.” A code, even laypeople know, is when the heart stops.

Mark thinks about the process for a moment and flashes one of his rare smiles. “It can be a miracle,” he says.

“Does it scare you anymore?”

“No,” he says. “I’m either enlightened or f–ked up.”

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Recently I tried to encourage someone to always find the good, always look for the opportunity to compliment and appreciate, and never complain or criticize.  Their response was, “But if you only knew that person, if you only knew how difficult they can be, and how much criticism they deserve.”

This response misses the point completely!  It was only when I dropped the contempt and criticisms did I start to see the gifts in the other person.  It is only when you look for the appreciation will the critical spirit in YOU fade away.

It is NOT about the other person; it is about YOU.  It is about healing YOUR image of yourself, the world around you, and others.

Our marriages and relationships would truly be transformed if we followed Carnegie’s first 2 principles always leading with this one.

“I consider my ability to arouse enthusiasm among my people…the greatest asset I possess, and the way to develop the best that is in a person is by appreciation and encouragement.  There is nothing else that so kills the ambitions of a person as criticisms from superiors.  I never criticize anyone.  I believe in giving a person incentive to work.  So I am anxious to praise but loathe to find fault.  If I like anything, I am hearty in my approbation and lavish in my praise… in my wide association in life, meeting with many and great people in various parts of the world… I have yet to find a person, however great or exalted his station, who did not do better work and put forth greater effort under a spirit of approval than he would ever do under a spirit of criticism.”-Charles Schwab

“Every man I meet is my superior in some way.  In that, I learned from him.”-Emerson

How to Win Friends and Influence People by Carnegie:

• “That is what Schwab did.  What do average people do?  The exact opposite.  If they don’t like to think, they ball out their  subordinates; if they do like it, they say nothing.  As the old couplet says: “once I did bad and that I heard ever/twice I did good, but that I heard never.”-pg 38
• “I once succumbed to the Fad of fasting and went for six days and nights without eating… I was less hungry at the end of the sixth day than I was at the end of the second.  Yet I know, as you know, people who think they had committed a crime if they let their families or employees go for six days without food; but they will let them go for six days,  six weeks, and sometimes 60 years without giving them the hearty appreciation that they crave almost as much as they crave food.”-pg 40
• ” When Alfred Lunt, one of the great actors of his time, played the leading role in Reunion in Vienna, he said, “there is nothing I need so much as nourishment for my self-esteem.”  We nurish the bodies of our children and friends and employees but how seldom do we nurish their self-esteem?  We provide them with roast beef and potatoes to build energy, but we neglect to give them kind words of appreciation that would sing in their memories for years like the music of the morning stars.”-pg 40 one
• “When we are not engaged in thinking about some definite problem, we usually spend about 95% of our time thinking about ourselves.  Now [just imagine], if we [ could] stop thinking about ourselves for awhile and begin to think of the other person’s good points…”-pg 41
• “Try leaving a friendly trail of little sparks of gratitude on your daily trips.  You’ll be surprised how they will set small flames of friendship that will be rose beacons on your next visit.”-pg 42
• “Pamela Dunham of  a New Fairfield, Connecticut, had among her responsibilities on her job the supervision of a janitor who was doing a very poor job.  The other employees would jeer at him and litter the hallways to show him what a bad job he is doing.  It was so bad, productive time was being lost in the shop.  Without success, Pam tried various ways to motivate this person.  She noticed that occasionally he did a particularly good piece of work.  She made a point to praise him for it in front of the other people.  Each day the job he did all around got better, and pretty soon he started doing all his work efficiently.  Now he does an excellent job and other people give them appreciation and recognition.  Honest appreciation got results where criticism and ridicule failed.”-pg 42
• “Hurting people not only does not change them, it is never called for.  There is an old saying that I’ve cut out and pasted on my mirror where I cannot help but see it every day: ‘I shall pass this way but once; any good, therefore, that I can do or any kindness that I can show to any human being, let me do it now.  Let me not deferring or neglect it, for I shall not pass this way again.'”-pg 42
• “Let’s cease thinking of our accomplishments, our wants.  Let’s try to figure out the other person’s good points.”-pg 43

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Time and time again  I have found myself using (or trying to use) his principles in my marriage, parenting, and other relationships.

Recently I have had conversations about affirming and its counter–criticizing your spouse.  I have seen and heard about a wife or husband who continually criticizes their spouse.  I have been a master at this myself.  For the most part, I have made a major effort to STOP completely this process.  It is a waste of time, and it turns out to do the opposite of what you want it to.  We seem to think that by giving ‘constructive criticism’ the other person will improve, but they don’t.  In fact, they seem to do MORE of the actions that we want them to change!

2 things:  1. The more you affirm and not criticize; the MORE likely their behavior will change!   2. Don’t try and change your spouse; just love them the way they are!

Principle #1: Don’t Criticize, Condemn, Complain

• “If you want to gather honey, don’t kick over the beehive.”
• “Criticism is futile because it puts a person on the defensive and usually makes him strive to justify himself.  Criticism is dangerous, because it wounds a person’s precious pride, hurts his sense of importance, and arouses resentment….B.F. Skinner, the world-famous psychologist, proved through his experiments that an animal rewarded for good behavior will learn much more rapidly and retain what it learns far more effectively than an animal punished for bad behavior.”
• “Lincoln…had learned by bitter experience that sharp criticisms and rebukes almost invariably end in futility.”
• “The secret of…Ben Franklin’s…success? ‘I will speak ill of no man…and speak all the good I know of everybody.”
• “Any fool can criticize, condemn and complain–and most fools do.  But it takes character and self-control to be understanding and forgiving.”
• “As Dr. Johnson said: ‘God himself, sir, does not propose to judge man until the end of his days.’  Why should you and I?”

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